Provider Demographics
NPI:1407418288
Name:ELLIS, JOSHUA BRIAN (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:BRIAN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MORRIS STREET
Mailing Address - Street 2:PO BOX 1547
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25326-1547
Mailing Address - Country:US
Mailing Address - Phone:304-388-6004
Mailing Address - Fax:304-388-3360
Practice Address - Street 1:200 TANNER ST
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-1524
Practice Address - Country:US
Practice Address - Phone:304-415-7297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-02
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2414363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant